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Alcohol Withdrawal Syndrome (AWS)

Screening: CAGE questionnaire:

  • tried to Cut down
  • Annoyed by others complaining
  • Guilty about drinking
  • Eye-opener drink
  • (suspect alcohol dependence if 3+)

Predictors of withdrawal severity

  • nr prev detoxifications
  • quant and duration of drinking
  • high alc level { w/o signs of intox | with signs of withdrawal }
  • concurrent use of sedative-hypnotics
  • coexisting medical problems

Symptoms of AWS

may appear within hours of patient's last drink, usu peaking at 24-36hrs
DTs usu begin 48-72h after last drink, preceded by signs and symptoms or early withdrawal
failure to respond to recommended doses may suggest concurrent benzodiazepine abuse
  • anxiety
  • headache
  • agitation, restlessness
  • auditory disturbances
  • tactile disturbances
  • N&V
  • diaphoresis
  • tremor
  • icrd BP, HR, RR
  • seizures
  • delirium

AWS flow chart

    • src=revised Clinical Institute Withdrawal Assessment for Alcohol="CIWA-Ar": html; pdf (includes score chart);
    • default score per category=0
    • 5-15=mild withdrawal
    • 16-25=moderate withdrawal
    • 25-67=severe withdrawal;
  • AWS [default score per category=0]
    • 1=N&V ["Do you feel sick?"]
      • 1=mild N, no V
      • 4=intermittent N with dry heaves
      • 7=constant N, frequent dry heaves and vomiting
    • 2=Tremor
      • 1=invisible, but felt at fingertips
      • 4=moderate with arms extended
      • 7=severe, even with arms not extended
    • 3=Paroxysmal sweats
      • 1=barely perceptible sweating, moist palms
      • 4=beads of sweat on forehead
      • 7=drenching sweats
    • 4=Anxiety ["Do you feel nervous?"]
      • 1=mildly anxious
      • 3=moderately anxious, or guarded so anxiety is inferred
      • 7=equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
    • 5=Agitation
      • 1=somewhat more than normal activity
      • 4=moderately fidgety and restless
      • 7=paces back and forth or thrashes about
    • 6=Tactile disturbances ["Have you any itching, P&N sensation, burning or numbness, or do you feel bugs crawling on or under your skin?"]
      • 1=very mild
      • 4=moderately severe hallucinations
      • 7=continuous hallucinations
    • 7=Auditory disturbances ["Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing things you know are not there?"]
      • 1=very mild harshness or the ability to frighten
      • 4=moderately severe hallucinations
      • 7=continuous hallucinations
    • 8=Visual disturbances ["Does the light appear to be bright? Is the colour different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things you know are not there?"]
      • 1=very mildly sensitive
      • 4=moderately severe hallucinations
      • 7=continuous hallucinations
    • 9=Headaches, fullness in head ["Does your head feel different? Does it feel like there is a band around your head?"]
      • 1=very mild
      • 2=mild
      • 4=moderately severe
      • 7=extremely severe
    • 10=Orientation and clouding of sensorium ["What day is this? Where are you? Who am I?"]
      • 1=cannot do serial additions or is uncertain about date
      • 2=disorientation for date by <=2 calendar days
      • 3=disorientation for date by >2 calendar days
      • 4=disoriented for place and/or person
  • Treatment:
    • Day1:
      • AWS 1-4: watch and wait
      • AWS 5-15=mild AWS: 10mg chlordiazepoxide at each obs q4h
      • AWS 16-25=moderate AWS: 30mg chlordiazepoxide at each obs q4h, Pabrinex 1pair amps IV daily
      • AWS >25=severe AWS: 50mg chlordiazepoxide at each obs q 1h
      • special precautions group: age>70 or established ALD: use Lorazepam not chlordiazepoxide; COPD: monitor resp status; IHD
    • Day 2-5:
      • daily Thiamine 100mg bd PO
      • cumulative chlordiazepoxide dose on day 1 is the baseline dose
      • dcr baseline dose by 20% each day (give in 4 doses, afternoon and evening dose can be higher to provide night sedation)
      • stop chlordiazepoxide on day 6

Examples of Treatment Regimens for Alcohol Withdrawal [html]

  • Monitoring (with no medication)
    • Monitor the patient by administering the CIWA-Ar (see Figure 1) every 4 to 8 hours until the score has been lower than 8 to 10 points for 24 hours. Perform additional assessments as needed.
  • Symptom-triggered regimens
    • Administer the CIWA-Ar every hour to assess the patient’s need for medication.
    • Administer one of the following medications every hour when the CIWA-Ar score is at least 8 to 10 points:
      • Chlordiazepoxide (Librium), 50 to 100 mg
      • Diazepam (Valium), 10 to 20 mg
      • Lorazepam (Ativan), 2 to 4 mg
  • Fixed-schedule regimen
    • Administer one of the following medications every 6 hours:
      • Chlordiazepoxide, four doses of 50 mg, then eight doses of 25 mg
      • Diazepam, four doses of 10 mg, then eight doses of 5 mg
      • Lorazepam, four doses of 2 mg, then eight doses of 1 mg
    • Provide additional medication as needed when symptoms are not controlled (i.e., the CIWA-Ar score remains at least 8 to 10 points).
  • CIWA-Ar = Clinical Institute Withdrawal Assessment for Alcohol, revised. Adapted with permission from Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278:148.
Andreas Jostel,
20 Jan 2010, 04:32